Ethiopia crash

[fluffyflops 1,858]

Was out with a mate at TUI this weekend.  So far its cost them 20 million euros. 

They went to Titan and asked them could they wet lease from them. 

"Of course you can" said Mr Titan, "one slight problem is the Airbuses are leased out to Jet2.  So how you take the 757s and 767s from us"

So Tui will now run their 737 max routes on titans 757s and 767  this Summer.

 

Edited April 14, 2019 by tooting

[Garys 209]

Delly - Your points are very valid and I do agree. However lets not forget that this aircraft didn't experience any type of mechanical failure to the same severity as  the national air cargo 747-400  out of Bagram which rendered the aircrew helpless. Regardless of how or why they got there, this aircraft was flyable. I compare this accident similar to the Qantas A380 which compromised 21 out of its 22 systems during climb. The pilots on this flight handled the situation exceptionally and attests to the quality of training and selection of aircrew at the worlds leading airlines. I continue to keep my faith that pilots can still fly aircraft in non normal conditions, but if we are starting to turn the corner where the skills stop at hitting the AP button at 400ft, then the  future of pilotless aircraft cant come soon enough.

 

 

https://www.youtube.com/watch?v=om18cOWFL3Q

 

 

Edited April 14, 2019 by Garys

[KevinAu 441]

19 hours ago, DellyPilot said:

Sorry but that is ridiculous, a quick recap 

Except, they had been given notice already of exactly all those indications that they experienced. And also there is no evidence that they even began any kind of abnormal profile as they were supposedly trained to. Again, this is not meant to relieve boeing of liability, if that is what you are so against here, but the pilot performance is undeniably a factor in the crash and has to be considered for the sake of all other pilots. There is something to be learned here for next year’s crm class, don’t try to cover it up for the sake of blaming the manufacturer. I don’t expect them to not crash. But I do expect them to go to their abnormals profile. Because who knows, maybe if they had gotten out a checklist, they would not have turned that trim back on and lived. You may think they deserve a pass like the lionair crew does, but they don’t, because the lionair crew died so that the ethiopean crew could have a chance. You may think I am ‘dishonoring’ the ethiopean crew, but consider how you are ‘dishonoring’ the lionair crew for their sacrifice in alerting everybody of this danger hiding in the aircraft. That bulletin that the ethiopean crew had put in their manuals was written in the blood of the lionair people. They totally ignored it. To be as highly paid as they are, they certainly did not live up to their end of the bargain and their passengers died for it.

Edited April 14, 2019 by n4gix
Deleted excessive quote. Again!

[KevinAu 441]

12 hours ago, DellyPilot said:

Wonderfully put, but perhaps we could go further and say "below average" pilots after all 50% are below average by definition.

 

They have a phrase for this. ‘Normalization of deviance.’ When you accept non-compliance and rationalize it. That’s why we don’t train to a grade or a curve. You either pass or fail. You either met the standard or not. The standard is that you encounter a problem and you perform the required actions. Or not. 0 or 1. That’s it.

[Peter Webber 339]

33 minutes ago, KevinAu said:

They have a phrase for this. ‘Normalization of deviance.’ When you accept non-compliance and rationalize it. That’s why we don’t train to a grade or a curve. You either pass or fail. You either met the standard or not. The standard is that you encounter a problem and you perform the required actions. Or not. 0 or 1. That’s it.

Exactly. Being an "African pilot", I don't really know where this is going..

[Peter Webber 339]

Boeing cannot use that as an excuse....the Max has dangerous flaws...bottom line. Fix it now, don't try to fix the guys who operate it.

[Bobsk8 12,730]

46 minutes ago, Peter Webber said:

Boeing cannot use that as an excuse....the Max has dangerous flaws...bottom line. Fix it now, don't try to fix the guys who operate it.

It's much cheaper to blame the pilots than fix the aircraft. 

[KevinAu 441]

6 minutes ago, Bobsk8 said:

It's much cheaper to blame the pilots than fix the aircraft. 

You cannot turn a deliberate blind eye to the crew factors either.

[honanhal 1,420]

1 hour ago, KevinAu said:

They have a phrase for this. ‘Normalization of deviance.’ When you accept non-compliance and rationalize it. That’s why we don’t train to a grade or a curve. You either pass or fail. You either met the standard or not. The standard is that you encounter a problem and you perform the required actions. Or not. 0 or 1. That’s it.

The point is that by definition not every crew is going to be “exceptional,” even if they are “adequate” for purposes of certification. If the plane is set up so that the crew needs to problem solve completely without unforced errors in real time to avoid killing everyone on board when something relatively small but not completely uncommon goes wrong (I.e. bent AOA vane), people will die. And lo and behold, people have been dying.

This is not rocket science. It’s also not “normalization of deviancy.” You don’t have to think the Ethiopian crew necessarily did even a “good enough” or “adequate” job to see why a design that puts so much of the onus for not crashing the plane on pilots is simply a series of accidents waiting to happen given that human beings, even highly trained ones, make mistakes under pressure.

Imagine a car design that sometimes, on its own, initiated a violent 90-degree turn with no warning. Even if every driver of that car was aware of that particularity and knew at least in theory how to mitigate it in relatively short order, would that be a safe car to put on the road?

James

[Bobsk8 12,730]

30 minutes ago, honanhal said:

The point is that by definition not every crew is going to be “exceptional,” even if they are “adequate” for purposes of certification. If the plane is set up so that the crew needs to problem solve completely without unforced errors in real time to avoid killing everyone on board when something relatively small but not completely uncommon goes wrong (I.e. bent AOA vane), people will die. And lo and behold, people have been dying.

This is not rocket science. It’s also not “normalization of deviancy.” You don’t have to think the Ethiopian crew necessarily did even a “good enough” or “adequate” job to see why a design that puts so much of the onus for not crashing the plane on pilots is simply a series of accidents waiting to happen given that human beings, even highly trained ones, make mistakes under pressure.

Imagine a car design that sometimes, on its own, initiated a violent 90-degree turn with no warning. Even if every driver of that car was aware of that particularity and knew at least in theory how to mitigate it in relatively short order, would that be a safe car to put on the road?

James

I totally agree, it's like  building a car that has a defect and then stating that the driver wouldn't have crashed if it they had been a Nascar driver. Bottom line, Boeing tried to get away on the cheap, had the FAA in their pocket, and 350+ people are now dead because of it. 

[KevinAu 441]

2 hours ago, honanhal said:

The point is that by definition not every crew is going to be “exceptional,” even if they are “adequate” for purposes of certification. If the plane is set up so that the crew needs to problem solve completely without unforced errors in real time to avoid killing everyone on board when something relatively small but not completely uncommon goes wrong (I.e. bent AOA vane), people will die. And lo and behold, people have been dying.

This is not rocket science. It’s also not “normalization of deviancy.” You don’t have to think the Ethiopian crew necessarily did even a “good enough” or “adequate” job to see why a design that puts so much of the onus for not crashing the plane on pilots is simply a series of accidents waiting to happen given that human beings, even highly trained ones, make mistakes under pressure.

Imagine a car design that sometimes, on its own, initiated a violent 90-degree turn with no warning. Even if every driver of that car was aware of that particularity and knew at least in theory how to mitigate it in relatively short order, would that be a safe car to put on the road?

James

Again, my point is not that they had to survive it, but that they should have made an attempt at doing what they were trained to do...an abnormal profile...that’s all. Because that would have at least possibly kept them from doing the thing that killed them. That’s the reason the abnormals are there, to keep you from doing something that kills you. They would have had a chance if they followed one of the most basic pieces of training. This is not about being exceptional, it is about remembering your most basic training.

If you’ve never flown for the military or the airlines, you probably don’t really understand what I am saying. If you’ve only ever flown pmdg at home, then at least you are familiar with ‘set thrust...thrust set...80kts...checks...v1...rotate’. Well, that’s actually a very specific and defined set of words that mean certain things are being done. It’s part of what we call a profile. For example, where I fly the E190, we say ‘speed alive’ at the beginning of the takeoff roll. It means a lot of things. It means that the pm has verified all airspeed indicators are increasing, verified that takeoff and autothrottle modes on the fma have turned green, and verified that the thrust compensation has armed green. If any one of those things is not verified, the problem is called out and the takeoff is aborted, there is no ‘airspeed alive’ in that case.

So just as there is a specific procedure each takeoff, airlines also train a specific procedure for abnormals, that applies to any abnormal, be it an engine failure at v1 or the most minor of eicas cautions. For me, our trained procedure for any, and I say any abnormal, has us first asserting who has and maintaining control of the aircraft, second, call out any applicable memory item, thirdly, call for any applicable qrc procedure (the checklists on the covers of the qrh), then the captain assesses and determines who will fly, which is usually going to be the fo, then the qrh is called for. So for an abnormal at my airline and previous airline, what you should hear on the cvr goes something like ‘Ding!....gen one off bus eicas...alright, i have control....memory items....no memory items....qrc....no qrc....ok you have control....gen one off bus qrh...’ So I am looking for some evidence of this type of behavior from the report and I saw none evident. That’s why I say they never went to to their abnormal training. Which might have saved them or at least kept all the blame on boeing.

If the captain had found the strength to snap out of his funk, he would have yelled for the fo to go to some checklist, who maybe would have even got the right one because he seemed to have the wherewithal to know the trim cutouts probably have something to do here, and maybe the fo would then have been more helpful by reminding him of things like, trim her up with your switch, or pull the power back and slow down, or it says here to leave the trim cutout. Any of which would have broken the chain. If they had done what, if ethiopean is like other airlines, they were trained to do, which is the abnormal profile, then even if they still crashed, it would all be on boeing, but they didn’t, so some of it has to fall on them. And this should stand as a reminder to pilots the importance of being ready to do their abnormals on any flight. That is why you should not brush crew actions under the rug for this crash.

Edited April 14, 2019 by KevinAu

[Bert Pieke 7,585]

Sorry if this is old news... but this is an exceptionally well presented analysis

 

[Mikelab6 89]

Great video ! Thanks for sharing..  That explains a lot of things to help us better understand the systems.

Mike

[honanhal 1,420]

5 hours ago, KevinAu said:

Again, my point is not that they had to survive it, but that they should have made an attempt at doing what they were trained to do... 

I don’t think we disagree about this. But I maintain the point about it being a dead end to rely on excellent pilotage to save lives is a critical one, because inevitably not all pilots will be excellent at all times.

Clearly, I’m not arguing that crew training and proficiency don’t matter. Obviously they do! But I also don’t think in this case a simple percentage allocation of blame makes sense, with a zero sum between Boeing and the pilots. If (as seems arguably to be the case based on what we know) the plane was effectively repeatedly doing its damndest to kill everyone on board, is it really the pilots’ “fault” in a meaningful way if they then proceed to make mistakes, without which they might have saved their and others’ lives?

I don’t think that question has an easy answer, genuinely.

[DellyPilot 109]

12 hours ago, KevinAu said:

Because who knows, maybe if they had gotten out a checklist, they would not have turned that trim back on and lived. 

This is wrong, the TRIM RUNAWAY checklist does not say do not re-engage STAB TRIM.

Yes it is mentioned in the November OMB but as you well know pitch was rapidly reducing, the FO couldn’t move the wheel and he was struggling to keep the nose up. He probably probably felt he had no choice, and if he had read the LionAir preliminary report he would known that the previous flight that landed safely had over 10 MCAS events, perhaps he thought we are high enough to risk it. Let's wait till we hear the CVR before all these assumptions.

 

12 hours ago, KevinAu said:

Except, they had been given notice already of exactly all those indications that they experienced.

Again not correct. The crucial factor in the 2nd crash which we didn't know at the time:

Speed + MCAS = STUCK TRIM WHEEL =  MAJOR PERIL

Another Boeing design flaw, another 50 year old design feature and yet another hole in the cheese not mentioned in the November OMB as an MCAS danger multiplier. 

https://theaircurrent.com/aviation-safety/boeing-nearing-737-max-fleet-bulletin-on-aoa-warning-after-lion-air-crash/

So yes they do deserve a pass like the LionAir crew. 

The one thing that was mentioned in the OMB was 'electric trim can be used to neutralise control column pitch forces before moving to cutout'. They actually did this! To me that was pretty impressive, pretty sure I would not have had the awareness to do that. 

I agree with cowpatz (please go read his post) we cannot expect pilots to be Chuck Yeager and work all this stuff out. You rather incredibly just assume you'd have been fine, well I know who I'd rather fly with out of you two. 

Self awareness, human factors and sensory overload are all crucial aspects to understanding how Boeing can improve training and their cockpit design (See 787 cockpit design) They failed on all counts because of cost cutting. 

 

12 hours ago, KevinAu said:

They have a phrase for this. ‘Normalization of deviance.’ When you accept non-compliance and rationalize it. That’s why we don’t train to a grade or a curve. You either pass or fail. You either met the standard or not. The standard is that you encounter a problem and you perform the required actions. Or not. 0 or 1. That’s it.

 

Kevin, there is always a bell curve. I got As at school but my buddy was way smarter and got the same. 

Unlike you I believe many good, average and below average crews who PASSED their checkride would have struggled here, did you see Mentour’s MCAS sim test (now deleted sadly)?

They had to turn the sim off because they were crashing! And that's with perfect hindsight, in daylight, not high and hot, no high ground, no fear of death, no shaker or clacker going!   

The captain was young but experienced, well trained and well spoken of and he PASSED all his compliance training. So what has to change? Just tell pilots to not under perform? 

No, Boeing need to stop grandfathering old air frames to cut costs, stop producing untested cr$p like MCAS (they seem to be struggling to even fix this) and maybe the thing we agree on, fix the training.